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‘Deep sleep’ and palliative care

The UK has inadequate care for the terminally ill

France legalizes “deep sleep” for the terminally ill

Palliative care has traditionally been for people with cancer

Many people are denied choices at the end of life

The process of ageing, and dying has become medical experiences

Thousands of palliative care patients in England often fail to receive sufficient pain relief and respite from other distressing symptoms. These are the findings of a 2015 London School of Economics Report, which raises concerns since the need for palliative care is large, and rapidly increasing as the population ages, with people over 85 projected to double in the next 20 years.

The Report exposes significant gaps in services, poor communication and unclear roles and responsibilities. “Part of the problem is that palliative care has traditionally been for people with cancer, and there is currently a lack of suitable models of palliative care for people with non-cancer and increasingly complex conditions,” says lead author Josie Dixon.

Non-cancer patients miss out

Those who currently miss out include: people over 85, those living alone, people living in deprived areas, and black, Asian and ethnic minority groups.

Only just over 20% of UK hospitals offer 7-day a week specialist palliative care, and the quality of hospital care is rated lower than a care home or a hospice. Despite over 70% of deaths being due to causes other than cancer – including respiratory illness, circulatory conditions and dementia – people with non-cancer diagnoses still account for only 20% of all new referrals to specialist palliative care services.

More than 56% of people now die in a care home within a year of being admitted, up from 28% in 1997. "These statistics show that care homes have a growing role in caring for people who are dying, but they need more support from GPs and specialists than currently exists," Dixon says.

The US experience

Whitfield Growdon, who teaches at the Harvard University Medical School and practices as an oncology surgeon at the Massachusetts General Hospital, Boston, suggests that the family is the primary provider of end-of-life care, and a major contributor to palliative care programs:

(click on the image to play the video)

France’s ‘deep sleep’

In March 2015 France passed legislation giving doctors new powers to place terminally ill patients in a “deep sleep” until they die, sparking controversy over whether euthanasia should be fully legalized. Polls show that 96% of French people support the “deep sleep” law, which will apply to patients who are conscious, but in “unbearable” pain, and whose treatment is not working or who decide to stop taking medication.

A President’s legacy

France legalised “passive euthanasia” in 2005, where treatment, needed to maintain life is withheld or withdrawn, but the government has refused to go further and allow full euthanasia, or assisted suicide, despite the huge public support. The new measures, passed by a comfortable majority in the National Assembly, will allow doctors to combine passive euthanasia with “deep and continuous sedation”.

The measure was a campaign promise by President Hollande who gave a commitment to allow the terminally ill afflicted by “unbearable” pain “to benefit from medical assistance to end their lives with dignity”. Anti-euthanasia groups criticised the legislation as “masked euthanasia”, but pro-euthanasia campaigners argue that it doesn’t go far enough, and would lead to terminally ill patients “dying of hunger or thirst”.

Takeaways

Ignorance, fear or anxiety about illness, death and dying can all have a negative impact upon our relationships with dying people. How can we better deal with the frailty of age, the onset of illness, and approaching death? In the 2014 BBC Reith Lectures, and in his latest book, Being Mortal: Medicine and What Matters in the End, Atul Gawande complains that we deny people choices of coping and autonomy at the end-of-life. “People live longer and better than at any other time in history. But scientific advances have turned the process of ageing, and dying into medical experiences; matters managed by health care professionals,” says Gawande.

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We should give up trying cure cancer

Leading cancer scientist says we should abandon looking for a cancer cure

Another leading cancer scientist discovers key to killing all cancers

Cancer is an inevitable consequence of our multicellular make-up

Each person's cancer is unique

One in three people will develop cancer in their lifetime

Every day 1,500 Americans, and more non-Americans, die of cancer

Most cancers cannot be cured and scientists should devote their efforts to preventing and managing the disease instead of trying to find a cure. That’s the view of Melvyn Greaves Professor of Cell Biology at the Institute of Cancer Research, UK.

Game changing cure for all cancers

Greaves’ suggestion comes at a time when Professor Philip Ashton-Rickardt, from Imperial College London discovered a previously unknown protean, which boosts the body’s ability to fight off any cancer or virus. “This is a completely unknown protein. Nobody had ever seen it before or was even aware that it existed. It looks and acts like no other protein . . . . It could be a game-changer for treating a number of different cancers and viruses,” says Ashton-Rickardt.

Unanswered questions about cancer

Cancer is an uncontrolled cell proliferation, propelled by mutant genes that invade our tissues and hijack essential body functions. Some regard this process as a ‘disease of the genome’. Around one in three of us will, at some time in our lives, be diagnosed with cancer; every day 1,500 Americans and vastly more non-Americans die of the disease. Missing from the narrative about cancer has been a coherent framework that makes sense of all its complexities and uncertainties: why are we so vulnerable to cancer, why is there so much diversity between different cancers, and even within single cancer types? And why does treatment so often fail or only temporarily succeed?

Mike Birrer, Professor of Medicine, Harvard University Medical School and Director of Medical Oncology, Massachusetts General Hospital describes the Cancer Genome Atlas, a landmark cancer research program, which begins to address some of these questions:

(click on the image to play the video)

Previously undiscovered protein

The protein discovered by Ashton-Rickardt, named lymphocyte expansion molecule, or LEM, promotes the spread of cancer killing T cells by generating large amounts of energy. Normally when the immune system detects cancer it goes into overdrive trying to fight the disease, flooding the body with T cells. But it quickly runs out of steam.

The new protein discovered by Ashton-Rickardt causes a massive energy boost, which generates T cells in such great numbers that the cancer cannot fight them off. It also causes a boost of immune memory cells, which are able to recognise tumors and viruses they have encountered previously so there is less chance that they will return. Ashton-Rickardt, whose studies to-date have been in mice, is hoping to produce a gene therapy whereby T cells of cancer patients could be enhanced with the protein, and then injected back into the body. In three years he expects to begin human studies. If successful, Ashton-Rickardt’s discovery could end the need for chemotherapies, as the body itself would fight the disease, rather than toxic drugs.

Alex Walther, consultant medical oncologist and Director of Research in Oncology at University Hospitals, Bristol describes the challenges of clinical trails in personalised molecular medicine:

(click on the image to play the video)

Need for smarter cancer strategies

Although sceptical about a cancer cure, Greaves has spent years unravelling the causes of childhood leukaemia by examining the genetic influences and biological pathways that lead to the disease. In 2008, breakthrough research led by Greaves and Professor Tariq Enver, achieved a world-first by confirming the existence of stem cells responsible for childhood acute lymphoblastic leukaemia.

Greaves insists that, “We need to get smarter. Very intelligent people who aren't scientifically minded think there must be a cause, there must be a cure, and it’s just not right. It’s fundamentally wrong . . . Talking about a cure for cancer in terms of elimination is just not realistic. . . . There are a few cancers that are curable, but most are probably not, including the common carcinomas in adults . . . . We should therefore not try to eliminate the cancer, we should try to hold it in check,” says Greaves.

Experts disagree

Leading cancer expert Professor Karol Sikora, is confident cancer cures could still be found, and finds Greaves’ pessimism, “Strange, given that Professor Greaves has done so much to help find a cure for leukaemia. I absolutely think we will find new cures in the future, and the closer we get to understanding the mechanism of the disease, the quicker this will happen.”

Professor Peter Johnson, chief clinician at Cancer Research UK agrees with Sikora, “We already have cures for many types of cancer. For example, millions of people who have had breast cancer, prostate cancer or bowel cancer are alive years after their surgery to remove the tumour, if it was caught early enough.”

Molecular Darwinism

Cancer researchers throughout the world are attempting to find cures for individual cancers using increasingly advanced methods. These include ramping up the body's own immune system to fight the disease; personalized treatments based on the DNA of the tumors, and gene therapies. But Greaves believes no therapy will work in the long term because tumors continue to evolve like all life forms. "Isn't it odd that when you read reports about new cancer therapies they work dramatically, but three months later, cancer is back with a bang. It's almost always the story" says Greaves.

In his book, Cancer: The Evolutionary Legacy, Greaves describes the Darwinian process by which cancer cells mutate, and diversify by natural selection within our tissue ecosystems. According to Greaves cancer is an inevitable consequence of our make-up as a multicellular reproductive animal. Since multicellular organisms have been around for 700 million years there has been a long time for cancer to evolve; and, without DNA mutation, we ourselves would not have evolved, and adapted into what we are. According to Greaves, "Cancer becomes a statistical inevitability of nature; a matter of chance and necessity."

Takeaways

Evolutionary principles derived from ecology, and the study of human evolution can change the way we think about the big question in cancer research. Will this provide new avenues for more effective cancer control or a cure?